PT Surgery Lec 3 PDF

## PTCUT ### PT SURGERY **Eyad Adham - Ahmed Sameh - Merna abdeeltawab** ## II-Post-operative physiotherapy after thoracic surgery ### Aims: 1. Assist in adequate relief of incision and/ or shoulder pain 2. Ensure optimal positioning postoperatively 3. Encourage bed mobility and early ambulation...

## PTCUT ### PT SURGERY **Eyad Adham - Ahmed Sameh - Merna abdeeltawab** ## II-Post-operative physiotherapy after thoracic surgery ### Aims: 1. Assist in adequate relief of incision and/ or shoulder pain 2. Ensure optimal positioning postoperatively 3. Encourage bed mobility and early ambulation 4. Minimize the chance for non-infectious (i.e. atelectasis & respiratory failure), and infectious (i.e. pneumonia) pulmonary complications 5. Promote re-inflation of lung areas of atelectasis & maintain adequate oxygenation 6. Clear patient's chest from excess retained bronchial secretions, and thus prevent chest infection 7. Prevent frozen shoulder on the thoracotomy side 8. Postural correction. 9. Mobilize thoracic cage to eliminate any restriction in expansion, and promote more efficient and deeper breathing. ## 1R Surgery Lec 3 **3 aims:** 1. Management of pain. 2. Post-operative positioning 3. Early mobilization ## 1 Management of postoperative pain: ### Pain Sites: 1. Incision 2. Drains (will be discussed later) ### Adverse effect of pain: 1. Ability to Cough → Sputum retention 2. Deep breath → Respiratory failure 3. ROM of Shoulder and Scapula → Frozen Shoulder 4. ↑ Anxiety 5. Sleep Disturbance 6. Induce Sympathetic Stimulation: * ↑ Respiratory rate, heart rate → ↑ Cardiopulmonary load * ↑ Blood pressure * ↓ Gut mobility → Difficulty defecating ## How to treat pain? 1. Pharmacological (drugs (analgesics)) 2. Non-pharmacological ## 1 Pharmacological ### There are 3 types of analgesics: 1. **Local analgesic:** Targets the incision * As the name suggests, it only affects the area of application 2. **General:** Affects the visceral pain * As the name suggests, it affects the entire body. 3. **Opiate:** Central effect * There are 8 different ways to administer opiates ### There are 8 different ways to administer opiates: 1. **Continuous epidural infusion:** * Catheter is placed inside the epidural space during the procedure * The catheter is then connected to a pump which is placed near the shoulder * The pump administers the medication ### There are 3 drugs commonly administered: 1. **Local anesthetic:** Bupivacaine 2. **Opiate:** morphine → fentanyl ## 2 Continuous intravenous infusion: * This method provides faster results than the IM method * However, it might cause respiratory depression * To avoid respiratory depression, we use PCA technique * PCA is similar but the patient controls the dosage ### Drugs: 1. **General:** Ketamine 2. **Opiate:** morphine, pethidine ## 3 Patient Controlled analgesia (CPCA) * Self administration. * The patient presses a button connected to a pump which administers a small dose of drugs. * There is a risk of overdosing by the patient. * To prevent overdosing, there’s a mini-period between doses “lock-out interval”. * This ensures that the patient will not receive an overdose even if they keep on pressing the button during the lock-out interval. ## 4) Patient Controlled Epidural analgesia (CPCEA) * Similar to PCA but administered into the epidural space * Advantages of CPCEA over PCA: * Requires lower doses of medication * Allows patients to control the dosage * Reduces anxiety * Eliminates delays ## 5) Paravertebral Block (CPVB) * Used in cases where it’s impossible to reach the epidural space. * The catheter is placed between the vertebrae. ### Drugs: 1. **Local anesthetic:** Bupivacaine, Ropivacaine ## 6) Intercostal nerve block (CICB) * Targets the nerve near the incision area ### Drugs: 1. **Local anesthetic:** Bupivacaine, Ropivacaine ## 7) Intramuscular injection: * Maximum concentration of blood is reached in 15-60 minutes * Provides analgesia for only 35% of the next 4 hours ### Drugs: 1. **Opiate:** morphine, pethidine ## 8) Oral drugs: * Not effective immediately postoperatively as the gut needs time to absorb the drugs. * Slow onset of action ### Drugs: 1. **Paracetamol** 2. **NSAIDS: ** idometacin 3. **Non-steroidal anti-inflammatory drugs** ## 2. Non-pharmacological ### Wound support: 1. **TENS** 2. **Cryotherapy** **Wound support:** * Allows patient to breathe deeply, cough, sneeze and facilitate deep breathing. * Physical therapist assistance. * Patient relies on pillows. * External thoracic support. ## **Images:** The document contains several images of different techniques to provide wound support for patients after thoracic surgery. The nurse’s hands should support the chest in anterior and posterior directions. The patient should be instructed to have several deep breaths while inhaling and then cough forcibly. The nurse should exert downward pressure on the patient’s shoulder with one hand and provide support beneath the wound with the other hand. The patient should be instructed to have several deep breaths while inhaling and then cough forcibly. A towel or sheet should be wrapped around the patient's chest, holding the ends together, while pulling gently during exertion. The nurse should release the towel or sheet during deep breaths. The patient should be taught to hold a pillow firmly against the incision while coughing. This can be done while lying down or sitting upright. ## 2) TENS * Complementary post-operative modality. * Used as a substitute (not as an adjunct). * Relieves incisional and ipsilateral shoulder pain. * Reduces mild to moderate pain, not severe pain * Intensity: strong but comfortable. * Frequency: 2-1OO Hz. * Duration: 20-30 min, three times a day. * Electrodes are placed parallel to the incision site. ### Mechanism of action: 1. Gate close of pain. 2. Stimulate release of endogenous opioids. ## 3) Cryotherapy * Ice packs can be used over painful sites but not directly over the skin. * It reduces the need for pain killers. ## 2 Post-operative positioning - Gravity assisted positions to improve ventilation and perfusion: - Upright position: - Improves ventilation - ↑ Diaphragmatic excursion - ↑ Oxygenation - ↑ Expiratory flow - Sidelying **Note:** The supine position is not allowed 1. **Thoracotomy:** Site of operation is on top 2. **Pneumonoectomy:** Site of operation is on the bottom - Gravity assisted positions to improve clearance of bronchial asthma: - Modified postural drainage (more preferable) - Classic postural drainage ## 3 Post-operative mobilization (Early mobilization) * Changing the patient position from supine to upright, or standing or walking. ### Aim: 1. **Stress** cardiopulmonary system 2. **↑** Cardiac output and minute ventilation **Benefits:** 1. **↑**(increase) Minute ventilation, and thus **↑** lung expansion → **↑** functional residual capacity (FRC). 2. **↑** Forced expiratory air flow -> Assists in clearing secretion 3. **↑** Cardiac output → Maintains adequate blood pressure and ensures good organ perfusion (Kidney) 4. **↓** Venous stasis → Prevents DVT and/or pulmonary embolism. 5. Prompts spontaneous exercise-induced deep breathing -> Stimulates coughing & expectoration of secretion → Prevents stagnation of secretion and infection. 6. **↓** Patient’s recovery time and prevents bedsores & muscle disuse atrophy. ### Safety guidelines for mobilization: 1. Assessment of hemodynamic stability (CHR, RR) 2. Clinical stable patient (these patients are ideal to start with) 3. Closely and well monitored (Vitals signs must be checked frequently) 4. Check drains, IV lines, tubes 5. Care about not dislodging the cap - If a cap is dislodged, stop the mobilization immediately, place a sterile dressing appropriately, and ensure appropriate medical help. 6. Ensure adequate analgesia 7. Assessment of motor and sensory function of lower limbs ## 9) Check for orthostatic hypotension: * **↓** in systolic BP > 20 mmHg * **↓** in diastolic BP > 10 mmHg * **Dizziness** * Begin with short steps and gradually increase the progression. ### Others: 1. 1/2 assistants are needed during mobilization 2. Drains must be kept below the PF level. 3. It is allowed to disconnect patients from wall suction and take them for a walk, but ensure communication with the medical staff. 4. Stair climbing can be done on the 4th or 5th day after surgery. 5. Borg scale can be used to assess patient’s level of exertion (use a gait belt to help) ### Contraindications of mobilization: 1. Hemodynamic instability 2. Severe hypoxemia at rest 3. HF, myocardial infarction, arrhythmia 4. Hypotensive patient 5. DVT 6. Pulmonary embolism, renal failure